Attachment 1 Requirements for the Online Initial Licensing Application~1.docx

Attachment 1. REQUIREMENTS FOR THE ONLINE INITIAL LICENSE APPLICATION

1 Overview This document contains the development requirements for the initial Full and initial Limited licensing processes.

A Full License allows a physician to practice medicine independently in the Commonwealth of Massachusetts. The same application process applies for an Administrative license (not conducting clinical practice) and for a Volunteer license (pro bono or charitable work).

A Limited License is issued to physicians enrolled in post-graduate training programs in health care facilities. All such training must be done in an Accreditation Council for Graduate Medical Education (ACGME)-accredited programs, or in a subspecialty clinical training or fellowship program in a training facility that has an approved program in the parent specialty.

A physician who holds or who has ever held a full Massachusetts license is not eligible for a Limited License.

1.1 Initial License Business Functions

The primary business functions are, as indicated in Section 3.1 of the RFR:

· Allow initial license Applicants to self-register and complete the Board's initial license application.

· For Limited Licenses, allow health care training facilities to register initial Limited License Applicants online before the Applicant can self-register.

· Allow initial license Applicants to pay initial licensing fees.

· For Limited Licenses, allow training facilities to review and submit a completed application to the Board.

· Allows the Applicant and training facilities, as applicable to Limited Licenses, the ability to track the progress of the application.

· Allows the Applicant and training facilities, as applicable to Limited Licenses, the ability to download and print certificates for initial Limited License Applicants that have been approved by the Board.

· Allows the Applicant and training facilities, as applicable to Limited Licenses, the ability to download, email, and print a PDF copy of the application.

· Import the initial license application into OnBase.

· Allow BORIM staff to review the application electronically; submit missing items notices to the Applicant and training facilities as applicable; approve or deny applications; and note any changes in status of application.

· Allow BORIM staff to scan and upload material received in BORIM by US Mail or ground delivery

· Allow BORIM supervisory staff the ability to assign and manage the Licensing Analysts and their workload.

· Allow BORIM users to access information via standard reports, scheduled reports, and self-service reporting capabilities.

1.2 Initial Full License Application Process

1.2.1 Full License Application Phase

1) The Applicant registers by entering Email address, User ID, Password, and a Challenge Question.

2) The application is prepopulated with existing data, if applicable

3) The Applicant completes the initial Full application and electronically signs the application. The Applicant makes electronic payment. The Applicant is given the option to print the initial Full application, and the Applicant is given the option to print a payment receipt.

4) BORIM receives the electronic application

5) The Applicant can print pre-populated forms to send documentation to BORIM or to request third parties to send required paperwork to BORIM as applicable.

6) Primary Source information sent from the Applicant or external sources by US Mail or ground delivery.

7) Primary Source information received at BORIM

8) BORIM Prep Analyst reviews and manually stamps paper based Primary Source information for completion and annotates in the system that it is received

9) Primary Source Information is scanned and added to the application

10) The Supervisor assigns a Licensing Analyst.

1.2.2 Full License Review Phase

11) The assigned Licensing Analyst reviews the submitted application and materials received to date.

12) The Licensing Analyst informs the Applicant of any missing items.

13) The Licensing Analyst addresses any affirmative answers with the Applicant and requests any additional documentation.

14) Missing item notices provided to the Applicant

15) Requested items returned to BORIM.

16) Received items are scanned and added to the application

17) The Licensing Analyst reviews application content, and refers the application to the Licensing Supervisor for disposition.

1.2.3 Full License Supervisor Review Phase

18) Licensing Supervisor reviews the application, and may request additional items from the Licensing Analyst and the Applicant. Received items are scanned and added to the application. After review, the Licensing Supervisor may determine that a U.S. Medical Graduate application is sufficient and may make the application Ready for Board Review, otherwise the Licensing Supervisor may refer the application to the Licensing Director for further review as required.

19) The Licensing Director reviews the referred application and may request additional items from the Licensing Analyst and the Applicant. Received items are scanned and added to the application.

20) After review, the Licensing Director may determine the application is sufficient and may make the application Ready for Board Review, otherwise the Licensing Director may refer the application for legal review as required. The application can be referred to either Licensing Legal or the BORIM Division of Law and Policy (DLP) for review and preparation for consideration by the Board’s Licensing Committee.

21) For International Medical Graduates (IMG) only, the Licensing Supervisor refers the application to the Licensing Director to review the medical education source documents. The Licensing Director reviews the source documents and may request additional items from the Licensing Analyst and the Applicant. Received items are scanned and added to the application. A sufficient IMG application is made Ready for Board Review.

22) The Licensing Committee reviews the application as required. The Licensing Committee may request that Legal obtain additional items from the Applicant. Received items are scanned and added to the application. A sufficient application is forwarded for Board approval with the other licenses ready for approval. Recommended Denials and Referrals (no recommendation) are forwarded to the Board. A Deferral at this point terminates the Licensing process at this time.

1.2.4 Full License Board Action Phase

23) Supervisor consolidated all recommended applications for approval and prints a .pdf list of recommended Applicants.

24) Consolidated applications are marked as “Ready for the Board”.

25) Criminal Offender Record Information (CORI) Check completed. An Unsatisfactory result will terminate the current application process.

26) Board approves Consolidated Applications in the Board meeting.

27) Board reviews recommended Denials and Referrals. Satisfactory applications are approved in the Board meeting, and unsatisfactory applications begin the Denial process.

28) Consolidated applications are collectively marked Approved in the system.

29) Individual Board approvals are marked Approved in the system.

30) Denials are marked for Preliminary Denial or Final Denial as applicable

31) Certificates printed and mailed to the Applicant, and are available to the Applicant to print and download.

32) Wallet Cards printed and mailed to the Applicant.

33) Final applications are retained in OnBase

1.3 Initial Limited License Application Process

1.3.1 Generate Limited Applicant Registration Letter

The Training Facility initiates an application by entering Applicant full name, training program name and address, and position. The Training Facility address will serve as the Applicant’s mailing address.

The Training Facility selects whether the Applicant or the Training Facility will pay the licensing fee.

The Training Facility prints a Registration Letter for the Applicant that contains:

· Applicant Name

· Position

· Program Start Date

· Program End Date

· Registration Code

· Training Facility Code

· Instructions for registering for an initial license on OLR

The Training Facility prints out the Registration Letter and provides it to the Applicant with other printed program-related information.

1.3.2 Limited License Application Phase

1) The Applicant registers by entering the information which must exactly match the Registration Letter. To complete the registration, the Applicant enters Email, User ID, Password, and a Challenge Question

2) The application is prepopulated with existing data if applicable

3) The Applicant completes the Initial Limited application and electronically signs the application. Note that if the Applicant does not currently have a US SSN, they will be directed to the SSN Affidavit page. If applicable, the Applicant makes electronic payment. The Applicant is given the option to print the initial Limited License application, and the Applicant is given the option to print a payment receipt.

4) The Program receives the electronic application

5) The Applicant can print pre-populated forms to send documentation to BORIM or to request third parties to send required paperwork to the Training Facility or BORIM as applicable.

6) An International Medical School Graduate Applicant is directed to the ECFMG site to request ECFMG Certificate if not already completed.

7) The Training Program completes the Online application

a) Each completed application will have a checklist of required forms for that application.

b) Part B of the application is signed by appropriate Training Facility staff on the Training Facility website.

c) The Training Facility user is required to print out a Supporting Documentation cover sheet. The cover sheet has a list of documents required for the application and an application ID that will be used by BORIM Licensing staff to search for the application.

d) Facility makes electronic payment by credit card or by electronic funds transfer (EFT).

8) BORIM receives the Online Application

9) Primary Source information sent from the Applicant, the Program, or external sources via US Mail or ground delivery.

10) Primary Source information received at BORIM

11) BORIM Prep Analyst reviews and manually stamps paper based Primary Source information for completion and annotates in the system that it is received

12) Primary Source Information is scanned and added to the application

13) The Supervisor assigns a Licensing Analyst.

1.3.3 Limited License Review Phase

14) The assigned Licensing Analyst reviews the submitted application and materials received to date.

15) The Licensing Analyst informs the Training Facility of any missing items.

16) The Licensing Analyst addresses any affirmative answers with the Training Facility and requests any additional documentation.

17) Missing item notices provided to the Applicant and the training program, as applicable

18) Requested items returned to BORIM.

19) Received items are scanned and added to the application

20) The Licensing Analyst reviews application content, and refers the application to the Licensing Supervisor for disposition.

1.3.4 Limited License Supervisor Review Phase

21) Licensing Supervisor reviews the application, and may request additional items from the Licensing Analyst and the Applicant. Received items are scanned and added to the application.

22) After review, the Licensing Supervisor may determine that a U.S. Medical Graduate application is sufficient and may make the application Ready for Board Review, otherwise the Licensing Supervisor may refer the application to the Licensing Director for further review as required.

23) The Licensing Director reviews the application and may request additional items from the Licensing Analyst and the Applicant. Received items are scanned and added to the application.

24) After review, the Licensing Director may determine the application is sufficient and may make the application Ready for Board Review, otherwise the Licensing Director may refer the application for legal review as required. The application can be referred to either Licensing Legal or the BORIM Division of law and Policy (DLP) for review and preparation for consideration by the Board’s Licensing Committee.

25) For International Medical Graduates (IMG) only, the Licensing Supervisor refers the application to the Licensing Director to review the medical education source documents. The Licensing Director reviewing the source documents may request additional items from the Licensing Analyst and the Applicant. Received items are scanned and added to the application. A sufficient IMG application is made Ready for Board Review.

26) The Licensing Committee reviews the application as required. The Licensing Committee may request that Legal obtain additional items from the Applicant. Received items are scanned and added to the application. A sufficient application is forwarded for Board approval with the other licenses ready for approval. Recommended Denials and Referrals (no recommendation) are forwarded to the Board. A Deferral at this point ends the process.

1.3.5 Limited License Board Action Phase

27) Supervisor consolidates all recommended applications for approval.

28) Consolidated applications are marked as “Ready for the Board”

29) Board approves Consolidated Applications in the Board meeting.

30) Board reviews recommended Denials and Referrals. Satisfactory applications are approved in the Board meeting, and unsatisfactory applications begin the denial process.

31) Consolidated applications are collectively marked “Approved” in the system.

32) Individual Board approvals are marked “Approved” in the system.

33) Denials are marked for Preliminary Denial and Final Denial as required.

34) Certificates are available to the BORIM staff and the Training Facility to print and download.

35) Final applications are retained in OnBase 2 Initial Licensing Functional Requirements This section will contain the functions required for Applicants to process an initial License application. Many functional requirements are common to both Limited and Full License applications, and are thus marked as “Common”. Requirements specific only to either Limited or Full are marked as such.

2.1 General Requirements and Business Rules

2.1.1 General Business Requirements

The flow of the Initial Full and Limited applications should emulate the Full License paper application included in Attachment 4. Where applicable, include the guidelines and instructions for each step as the step is performed by the Applicant.

All questions are considered to be mandatory and will prevent moving to the next step if incomplete, unless specifically indicated.

BORIM staff can add/delete/edit questions and data collection requirements on the application without vendor assistance to meet emergent regulatory requirements.

The application shall have ensured compatibility with current BORIM online tools for physicians and the general public, including Physician Profiles, Online Renewals, and Online Complaints.

The application shall support integration with the Federation Credentials Verification Service (FCVS), as able, and address further integration opportunities as FCVS systems mature.

If Supervisor is also the Analyst assigned to a given application, the Supervisor will complete all analyst and Supervisor tasks with no additional workflow between the roles.

Publicly - releasable and non-releasable data shall be segregated for reporting purposes to prevent inadvertent disclosure.

2.1.2 General Technical Requirements

The application shall be compliant with Google Chrome and Internet Explorer browsers (latest version) at time of production migration.

The application must be PCI-compliant to handle sensitive information regarding payments.

The application must have strong authentication to support user self-registration and subsequent system logins, leveraging current EHS enterprise-wide Authentication and Identity Management System.

The application shall support pre-production environments as required.

The solution must address data backup and restoration, and disaster recovery.

The application must be compatible with web services protocols.

Should the Bidder propose an on-premises solution, understand that the solution will be hosted by a Massachusetts EOTSS cloud hosting provider partner.

2.1.3 Preferred Solution Attributes

The following attributes are desirable and will be given preference in evaluation of the Technical response.

· Modular architecture.

· Strong Application Programming Interface (API) capability for data exchange

· Software as a Service (SaaS) solutions.

· Highly configurable with low customization.

· Solutions that are commercially off the shelf and provide regularly scheduled updates that are easy to implement.

· Solutions that can be supported by many vendors.

· Web-based solutions that are mobile-friendly.

2.2 User Registration (Common)

Users will be presented a login page where after an initial setup they will log into their Applicant console.

New users will have the ability to set up an account. The Limited process differs from the Full process in that the user will have to provide the Activation Code as received by the training program

If the Applicant selects “Register as a Full License Applicant,” they are directed to the Initial Application User Registration Information Page

If the Applicant selects “Register as a Limited License Applicant”, they are directed to the Initial Limited Application User Registration Validation Page

2.2.1 Initial Limited Application User Registration Validation Page (Limited Only) This User Registration Validation page will prompt the user for information to accurately identify the Applicant. This information is included on the Applicant Registration Letter. The information to be gathered from the Applicant:

· First Name

· Last Name

· Middle Initial

· Activation Code

· Training Facility Code

· Position

If the Applicant does not enter accurately enter all these fields accurately, an error message will be presented indicating not all data was entered accurately. The Applicant will be prompted to re-enter the information.

If the Applicant does enter all the fields accurately, the user will be taken to the User Registration Information page.

If the user chooses the option "I have a valid MA Limited License", the existing OLR registration page will be displayed.

2.2.2 Initial Application User Registration Information Page (Common) This User Registration Information page will prompt the Applicant for the following information:

· Username

· Password

· Password confirmation

· Email

· Email confirmation

· Challenge question

· Challenge question answer

When all the User Registration Information has been successfully entered, the Applicant will be allowed to start the application process.

2.3 Initial Full License Application

2.3.1 Full Landing Page (Full Only)

The Applicant will select the License Type from Initial Full License, Administrative License, and Volunteer License

The Applicant will indicate whether or not (Y or N) they are using the Federated Credential Verification Service (FCVS), and this information is retained for the Analyst to manually download and add information from FCVS.

2.3.2 Demographic and Address Page (Full Only)

The Applicant will be asked the following questions, and presented with the following statement:

· Have you ever held a Massachusetts Full License?

· Have you ever held a Massachusetts Limited License?

“If you have previously held a Massachusetts Limited License, you may be able to rely on previously-submitted information to help expedite the licensing process.”

If the answer regarding a prior Full License is “Yes”, the Applicant will be directed to the Apply to Reinstate a Lapsed Physician License page https://www.mass.gov/service-details/apply-to-reinstate-a-lapsed-physician-license

If the answer regarding a prior Limited License is “Yes”, the Applicant will be prompted to enter either the license number or SSN and data in the system for that Applicant will be prepopulated to the greatest extent in all flowing forms, which may be edited before submission of this application

The Applicant will enter the following fields:

· First Name

· Middle Name

· Last Name

· Degree type(MD, DO, PhD, Other)

The Applicant will be presented with the following question:

Have you used another name that appears on your identification documents, such as medical education and examination records?”

If the answer is “Yes”, the Applicant will be prompted for the following information, and up to five instances can be recorded:

· First Name

· Middle Name

· Last Name

The Applicant will be presented with the following text:

“You must provide photocopies of the following two required documents:

1. A current government issued photographic identification (e.g., driver license, passport, etc.); AND

1. One of the following additional legal documents as proof of name change:

Certified Court Order Marriage Certificate Divorce Decree”

The Applicant will have to option to upload the documents, or to choose to send a hardcopy by US Mail or ground delivery. BORIM anticipates that these uploads could exceed 10MB.

The system shall accept at a minimum the following formats: .doc, .rtf, .txt, .pdf.

Upon upload, this item will indicate as completed in the Applicant’s checklist.

If the Applicant chooses not to upload the documents, a Name Change Form to accompany the documents will be available for download and print after completion of the application.

The form will be prepopulated with the Applicant’s information, and will be returned to BORIM by US Mail or ground delivery.

The following fields must be on the page and are required fields:

· National Provider Identifier (NPI) Number (if applicable)

· Mailing address

· Home Address

· Business Address

· Phone Number

· Gender

· Date of Birth

· Place of Birth (City, State, Country)

· SSN (mandatory for granting Full License) a "No SSN" checkbox will allow the user to not enter this field. This will force the user to complete the request for the Licensing Director to issue the documentation to assist the Applicant in obtaining a SSN.

· Email with data from registration page

2.3.3 Pre-Medical School Page (Common)

A separate page will also allow the Applicant to enter the Premedical school information, and up to five instances can be recorded:

· Premedical School

· Address

· City

· State

· ZIP Code Should the Applicant have not attended a post-secondary school other than their medical school, they will have the ability to check a box next to the following statement, and proceed to the next question:

“I did not attend a post-secondary school other than my Medical school”

2.3.4 Medical School Page (Common)

The user will be shown a radio button that will allow the Applicant to indicate graduation from a US Medical School or an International Medical School:

· Graduate of a Medical School in the United States, Canada, or Puerto Rico (USMG)

· Graduate of an International Medical School (IMG)

The Applicant will be presented with a dropdown of US, Canadian, and Puerto Rican Medical Schools, and a separate dropdown of International Medical Schools.

The Applicant will select all Medical schools attended, and for those where the Applicant graduated, the Applicant is required to indicate the medical school graduate date.

Also, the following medical school information is required for each:

· Start and End Dates of attendance

· Degree (MD, DO, Other with text, N/A)

The Applicant will have the ability to enter information should the Medical School not appear in the dropdown.

The following text and questions will be presented to the Applicant regarding their time in Undergraduate, Medical school, or Graduate programs (Not Medical Postgraduate programs). A Yes or No answer is required for each question. If the Applicant answers “yes” to any of the questions, the following fields must be presented to the Applicant to enter a supplemental explanation.

· Name of agency or institution taking action

· Start Date of action

· End date of action

· Detailed description There must be a separate supplemental explanation for each “Yes” answer.

“If you answer “yes” to any of the following questions, you must provide a detailed explanation and arrange for the appropriate institution to submit copies of all official documentation and correspondence related to the underlying occurrence or action. Documents should be sent directly to you in a sealed envelope.”

· While enrolled in college, medical school, or graduate school, were you ever the subject of any disciplinary action? (This includes action that was formal or informal, oral or written, voluntary or involuntary. A confidentiality agreement does not absolve you of your requirement to answer this question.)

· Have you ever been terminated from medical school?

· Have you ever withdrawn or transferred from a medical school?

· Have you ever been granted a leave of absence by a medical school? (This Includes a leave for research, public service, participated in a joint M.D./Ph.D. program, or for any other “personal reasons”)

· Have you ever been placed on probation or remediation by a medical school, or graduate school?

· If you are a US or Canadian graduate, did you take more than 4 years to complete medical school; or if you are an international medical graduate (IMG), did you take more than 6 years to complete medical school?

2.3.5 Post-Graduate Training Page (Common)

The Applicant will be asked the following question:

· Have you ever or are you currently engaged in postgraduate training in the U.S. or Canada?

If the answer is “Yes”, the Applicant will be prompted for the following information, and up to five instances can be recorded:

· Name of Postgraduate Training Program

· City

· State

· Training Start Date

· Training End Date

· Training Program

Training Program data will pre-populate the Timeline of Activities since Graduation table in Section 2.3.7.

If the answer is “Yes”, the following text and questions will be presented to the Applicant regarding their time in Postgraduate programs. If the Applicant answers “yes” to any of the questions, the following fields must be presented to the Applicant to enter a supplemental explanation.

· Name of agency or institution taking action

· Start Date of action

· End date of action

· Detailed description

There must be a separate supplemental explanation for each “Yes” answer.

“If you answer “yes” to any of the following questions, you must provide a detailed explanation and arrange for the appropriate institution to submit copies of all official documentation and correspondence related to the underlying occurrence or action. Documents should be sent directly to you in a sealed envelope.”

· While enrolled in postgraduate training, were you ever the subject of any disciplinary action? (This includes action that was formal or informal, oral or written, voluntary or involuntary. A confidentiality agreement does not absolve you of your requirement to answer this question.)

· Have you ever been suspended, terminated, or dismissed from any training program?

· Have you ever had to repeat a year of postgraduate training?

· Have you ever withdrawn or transferred from a postgraduate training program?

· Have you ever been granted a leave of absence from a postgraduate training program? (This Includes a leave for research, public service, medical leave, or for any other “personal reasons”)

· Have you ever been placed on probation or remediation by a postgraduate training program?

· Were any limitations or special requirements imposed on you because of questions of competency or disciplinary problems?

· Did you ever receive partial or no credit for a postgraduate training program?

· Have you ever had a postgraduate training program contract not be renewed?

2.3.6 License Examinations State Page (Full only)

The Applicant will be shown the following text along with a list of exams:

Please indicate all the licensing examinations that you have completed with either a Passing or Failing score, and the Number of times you have attempted the examination:

· USMLE

· Step 1

· Step 2 (CK)

· Step 2 (CS)

· Step 3

· NBME

· Part 1

· Part 2

· Part 3

· FLEX

· Component 1

· Component 2

· FLEX pre-1985

· NBOME

· Part 1

· Part 2

· Part 3

· COMLEX

· Level 1

· Level 2 (CE)

· Level 2 (PE)

· Level 3

· COMVEX

· MCCQE

· Part 1

· Part 2

· State Board Exam

Each of the examinations will have a checkbox for the Applicant to indicate a passing or failing score, and a field to enter the number of attempts.

If a State Board Exam is indicated, the user will be presented fields to enter the state and the year.

2.3.7 Timeline of Activities since Graduation (Common)

The Applicant is presented the following text and the table below to complete. The Training Program data entered in in Section 2.3.5 will pre-populate the Timeline. The timeline will enforce continuity and completeness such that any gap in the month/year data from Medical School graduation date to the present date will prevent the user from moving to the next question.

“Please provide a chronological listing by month and year of all activities since graduation from medical school. This would include all postgraduate training, research activities, hospital affiliations, medical staff appointments, faculty appointments, private practices, military assignments, locum tenens and telemedicine assignments and any other employment or volunteer activities. Also include periods of unemployment or any activities outside of the practice of medicine. You must account for any time gaps of 30 days or more since your graduation from medical school. Failure to complete this section or address any time gaps may result in delay of licensure.”

TIMELINE OF ACTIVITIES SINCE GRADUATION FROM MEDICAL SCHOOL

(mm/yyyy) Position Held (Resident, Attending, Research Fellow, etc.)

2.3.8 Curriculum Vitae Upload Page (Full only)

The Applicant will be presented with the following statement:

“You must submit a current Curriculum Vitae (CV).”

The Applicant will have to option to upload a CV, or to choose to send a hardcopy CV by US Mail or ground delivery. BORIM anticipates that these uploads could exceed 10MB.

The system shall accept at a minimum the following formats: .doc, .rtf, .txt, .pdf.

Upon upload, this item will indicate as completed in the Applicant’s checklist.

If the Applicant chooses not to upload a CV, a CV Cover Sheet to accompany the CV will be available for download and print after completion of the application.

2.3.9 Licensed in Other State Page (Common)

The Applicant will be shown the following text:

“Indicate whether you currently or have ever held a full license in the U.S. or Canada. This includes any active or inactive licenses. Do not report training or temporary licenses.”

The Applicant will be presented with a list of US states and Canadian provinces to select from. The list will include the full state name with standard 2-letter abbreviations in parentheses.

2.3.10 Certifications and Specialties Page (Full only)

The Applicant will be presented the following questions, and select “Yes” or “No” for each:

· Are you certified by the American Board of Medical Specialties?

· Are you certified by the American Board of Osteopathic Medicine?

The Applicant will select one or multiple Board Certifications from a dropdown. The source of available Board Certifications will be the American Board of Medical Specialties if the first question is answered “Yes”, and the American Board of Osteopathic Medicine if the second question is answered “Yes”.

The Applicant will select one or multiple Specialties from a dropdown, as applicable, and have the option to enter text if not found.

Upon selection of a Specialty, a dropdown with related Sub-specialties will appear. The source of available Specialties and Sub-specialties will be as for the Certifications above.

2.3.11 Opioid and Pain Management Page (Full only)

The Applicant will be asked the following question and accompanying text, and select “Yes” or “No”:

· Have you completed the Opioid and Pain Management training?

“Physicians who prescribe controlled substances (Schedules II - VI), must have completed at least three (3) credits of Board-approved continuing professional development in effective pain management. Physicians are responsible for determining whether the pain management continuing professional development requirement applies to them, based upon the nature of their practice. A free online resource to obtain the necessary credits is available at www.opioidprescribing.com.”

2.3.12 Recognize and Report Training Requirement Page (Full only)

The Applicant will be asked the following question, and select “Yes” or “No”:

· Have you completed training to recognize and report suspected child abuse or neglect?

“M.G.L. c. 119, §51A(k) requires all mandated reporters, professionally licensed by the Commonwealth, to complete training to recognize and report suspected child abuse or neglect. Physicians are one category of mandated reporters. Physicians may comply with the training requirement through:

· Receiving training in child abuse or neglect assessment in medical school education or postgraduate training;

· Completion of a hospital sponsored training program in recognizing the signs of child abuse and neglect;

· Completion of continuing professional development (formerly known as continuing medical education credits) in identifying and reporting child abuse and neglect;

· Completion of an on-line training program (i.e., The Middlesex Children’s Advocacy Center’s program “51A Online Mandated Reporter Training: Recognizing and Reporting Child Abuse, Neglect, and Exploitation” www.middlesexcac.org/51A-reporter-training); or

· Completion of a specialized certification (i.e., Child Abuse Pediatrics).

Full License Applicants must complete the requirement for training prior to submission of an application to the Board. This is a one-time requirement.”

If the answer is “No”, the Applicant will be presented with the following text:

“Your license will not be processed until you complete the required training.”

2.3.13 Domestic and Sexual Violence Education and Training (Full Only) The Applicant will be asked the following question and statement, and select “Yes” or “No”:

· “Have you completed the Massachusetts Department of Public Health online training in Domestic and Sexual Violence for licensed healthcare professionals?”

If the answer is “No”, the Applicant will be presented with the following text:

· “Your license will not be processed until you complete the required training, available at https://www.mass.gov/service-details/domestic-and-sexual-violence-integration-initiatives.”

2.3.14 MassHealth Enrollment Requirement Page (Common)

The Applicant will be asked the following question and statement, and select “Yes” or “No”:

· Have you applied to enroll in MassHealth as a nonbilling provider?

“Physicians (including interns and residents) are eligible to order, refer or prescribe services for MassHealth members and, under state law, must apply to enroll with MassHealth at least as ordering and referring (nonbilling) providers in order to obtain and maintain state licensure. Providers who are already enrolled with MassHealth have already met the requirement and do not need to take further action.”

If the answer is “No”, the Applicant will be presented with the following text

“MassHealth has created a Nonbilling Provider Application for providers in provider types that are not eligible to enroll as fully participating providers. This application can also be used by providers who are eligible to enroll in MassHealth as fully participating providers but who choose not to at this time. Physicians must apply to enroll with MassHealth at least as ordering and referring (nonbilling) providers in order to obtain and maintain state licensure.

Providers who wish to apply to enroll as a nonbilling provider, download the materials from the MassHealth website at http://www.mass.gov/eohhs/docs/masshealth/aca/pe-nbp-con.pdf and send the completed and signed Nonbilling Provider Application and Contract by mail to the MassHealth Customer Service Center at:

MassHealth Customer Service Center Attn: Provider Enrollment and Credentialing P.O. Box 121205 Boston, MA 02112-1205 Providers who have questions, or if eligible, would like to request a fully participating provider application should contact the MassHealth Customer Service Center at 1-800-841-2900 with any questions or, if eligible, to request a fully participating provider application.”

2.3.15 Electronic Health Record Proficiency Requirement Page (Full)

The Applicant will be asked to respond by selecting the appropriate entry dropdown boxes presented below:

“ELECTRONIC HEALTH RECORDS (EHR) PROFICIENCY FORM

Pursuant to M.G.L. c. 112, § 2, an Applicant for licensure must demonstrate proficiency in the use of electronic health records (EHR). This is a one-time requirement.

Complete Section 1 (Demonstrating Proficiency) OR Section 2 (Claiming an Exemption)

SECTION 1. DEMONSTRATING PROFICIENCY

I have demonstrated proficiency in the use of EHR in one of the following ways:”

Dropdown menu includes:

· Participation in a Meaningful Use program as an eligible professional

· Employment with, credentialed to provide patient care at, or in a contractual agreement with an eligible hospital or critical access hospital with a CMS Meaningful Use program

· Participation as either a Participant or an Authorized User in the Massachusetts Health Information HIway

· Completion of 3 hours of a Category 1 EHR-related CPD course that discusses, at a minimum, the core and menu objectives and the Clinical Quality Measures (“CQMs”) for Meaningful Use

“SECTION 2. CLAIMING AN EXEMPTION (Exemptions must be claimed each licensing cycle, if applicable. If you are exempted from the EHR proficiency requirement, please select the appropriate exemption.)

I am exempt from the EHR Proficiency requirement because I am an Applicant”

Dropdown menu includes:

· who will not be engaged in the practice of medicine as defined in 243 CMR 2.01(4)

· for an Administrative License

· for a Volunteer License

· on active duty as a member of the National Guard or of a uniformed service called into service during a national emergency or crisis

· for an Emergency Restricted License

2.3.16 Massachusetts Licensing Information Page (Full Only)

The Applicant will be asked the following question, and provide a written answer:

· For what reason are you requesting a Massachusetts medical license?

Answering this question is not mandatory for continuing to the next step.

The Applicant will be presented with the following field to select from a dropdown, as applicable, and have the option to enter text if not found:

· Facility Name

The Applicant will be asked to select the anticipated start date in Massachusetts.

Answering this question is not mandatory for continuing to the next step.

2.3.17 Questions Page (Common)

The following text and questions will be presented to the Applicant. A Yes or No answer is required for each question. If the Applicant answers “yes” to any of the questions, the following fields must be presented to the Applicant to enter a supplemental explanation.

· Name of agency or institution taking action

· Start Date of action

· End date of action

· Detailed description There must be a separate supplemental explanation for each “Yes” answer.

“Actions by any Health Care Facility, Employment, Professional Organization, State Board or any other Governmental Agency If you answer “yes” to any of these questions, you must provide a detailed explanation and arrange for the appropriate agency or institution to submit copies of all official documentation and correspondence related to the underlying occurrence or action. Documents should be sent directly to you in a sealed envelope.”

· Have you been denied the privilege of taking or finishing an examination or been accused of or found to have cheated or engaged in improper conduct during an examination?

· Have you ever been denied a medical license, whether full, limited or temporary, or have you withdrawn an application for medical licensure?

· Have you ever surrendered a license to practice medicine or any professional license or has your license or certificate ever been revoked? (You do not need to report a lapsed license.)

· Have you been denied American Board of Medical Specialties or American Board of Osteopathic Medicine certification or has your certification ever been suspended or revoked?

· Are you aware of any pending investigation or inquiry into your professional conduct by any entity, or are any disciplinary charges pending against you?

· Since your completion of postgraduate training, has any disciplinary action ever been taken against you? (A confidentiality agreement does not absolve you of your requirement to answer this question.)

· Has your medical staff membership, medical privileges, medical staff status or association with a health care facility ever been limited, suspended, revoked, not renewed or subject to probationary conditions, or has processing toward any of those ends been instituted or recommended by a medical staff committee, administration or governing board?

· Have you ever withdrawn an application for hospital privileges or appointment, or have you ever been denied medical staff membership, advancement in medical staff status or association with a health care facility, or has such denial been recommended by a medical staff committee, administration or governing body?

· Has your privilege to manufacture, distribute, administer, possess, dispense or prescribe controlled substances ever been suspended, revoked, denied, restricted or surrendered, or have you ever been called before or warned by any state or other jurisdiction, including a federal agency, regarding such privileges?

· Has any professional liability insurance provider ever restricted, limited, terminated, imposed a surcharge or co-payment, or placed any condition on your coverage, or have you ever voluntarily restricted, limited or terminated your insurance coverage in response to any inquiry by a professional liability insurance provider?

· Have you ever had an application for membership as a participating provider denied by any third-party payor, Medicare or Medicaid (any state), or have you ever been the subject of any termination, suspension or probation proceedings instituted by any third-party payor, Medicare or Medicaid (any state), or have you ever been restricted from receiving payments from any third-party payor, Medicare, or Medicaid (any state)?

2.3.18 Criminal History Page (Common)

The Applicant will be asked the following question, and presented with the accompanying text:

· Have you ever been charged with any criminal offense?

“IMPORTANT NOTE: You must report being arrested, arraigned, indicted or convicted, even if the charges against you were dropped, filed, dismissed, or otherwise discharged. A charge of operating under the influence or its equivalent is reportable. A medical malpractice claim is a civil, not a criminal, matter and need not be reported for purposes of this question. If in doubt as to whether an arrest or criminal offense must be disclosed, it is best to disclose the action on your application.

Expunged/Sealed Offenses: While expunged offenses, arrests, tickets or citations need not be disclosed, it is your responsibility to ensure the offense, arrest, ticket or citation has, in fact been expunged or sealed. Failure to reveal an offense, arrest, ticket or citation that is not in fact expunged or sealed, raises questions related to truthfulness in addition to questions regarding the offense itself. You may have been told your record is expunged or sealed when in fact it is not. If, during the course of the application process, information about an offense is discovered which you did not disclose because you believed it to be expunged or sealed, you will be required to provide a copy of the expunction or sealing order.”

If the Applicant answers “yes”, the following text and fields must be presented to the Applicant to enter a supplemental explanation. The option to create a new form is presented, and all data is retained.

“Provide a detailed written explanation Do not write “See attached”. You must provide your response on this form.

Supporting Documentation: For each criminal proceeding in which you were named a defendant, certified copies of the complaint, judgment or other disposition and a copy of the police report must be sent to you in sealed envelopes from your lawyer, the court or other appropriate agency. The sealed envelopes must be included with your Full License application. You must also provide a detailed explanation of the incident, including date, time, place, the court action and final disposition. If a court, an arresting/ticketing agency or your lawyer is unable to provide copies of applicable records, request that they furnish a written statement to that effect which should be sent to you in a sealed envelope.”

Current Probation Agreement in another State It is the practice of the Licensing Committee, a committee of the Board of Registration in Medicine, to defer action on applications from individuals with a current probation agreement in another state, until that state’s medical board has terminated the probation.”

· Incident Date

· Location of Incident (City and State/Country)

· Arresting/Ticketing Agency

· Court

· Initial Charge(s)

· Initial Charge(s) Misdemeanor or Felony

· Final Charge(s)

· Final Charge(s) Misdemeanor or Felony

· Plea

· Disposition: (if probation, deferred adjudication, or deferred prosecution give summary.)

· Detailed Summary. Provide a personal statement containing a detailed summary of the events and circumstances leading to this arrest, citation, ticket, criminal charge and/or investigation:

2.3.19 Malpractice History Page (Common)

The Applicant will be asked the following question:

· Has any medical malpractice claim ever been made against you, whether or not a lawsuit was filed in relation to the claim or has such a suit been settled, adjudicated or otherwise resolved?

If the Applicant answers “yes”, the following text and fields must be presented to the Applicant to enter a supplemental explanation. The option to create a new form is presented, and all data is retained.

“MEDICAL MALPRACTICE HISTORY

For each instance of alleged malpractice, you must provide the following information.”

General Claim Information:

· Claimant’s name/initials

· Date of incident

· Professional Liability Carrier’s name

· Legal representative’s Name

Status of Claim:

· Current status of claim (select Closed or Pending)

· Was a lawsuit filed in relation to the claim (select Yes or No)

· If the claim resulted in a lawsuit, what was the final outcome of the suit? (select from Dismissed before trial; Plaintiff Verdict; Defense Verdict; or Other (please specify)

· Explanation (mandatory if “Other” selected)

· Was the claim settled by you or on your behalf, with or without the filing of a lawsuit? (select Yes or No) “If a payment was made on your behalf, either as a result of a settlement or an award of damages:”

· Amount allocated to you($)

Malpractice Claim Descriptive Information:

· Allegation(s)

· Alleged Patient Injury

· Patient’s condition at point of your involvement

· Patient’s condition at end of treatment

· Detailed summary, including the nature and extent of your involvement with the patient, your degree of responsibility for the course of treatment leading to the claim, and , if incident resulted in patient’s death, indicate cause of death according to autopsy or patient chart

“In addition to the information listed above, you must arrange for your lawyer or liability carrier to submit a copy of the following documents directly to the Board for the following malpractice cases:

Pending Claim

1) a malpractice history report from your malpractice liability carrier or letter from your attorney that include the claimant’s name/initials and confirmation that the claim is open/pending; and

2) a copy of the Complaint, Notice of Intent to File a Claim Letter or other claim letter.

Closed Claim

1) a malpractice history report from your malpractice liability carrier or letter from your attorney that includes the claimant’s name/initials, final disposition of the claim, and the amount of the payment, if any, that was made on your behalf;

2) a copy of the Complaint, Notice of Intent to File a Claim Letter or other claim letter; and

3) a copy of the final judgment, settlement and release or other final disposition of each claim, even if you were dismissed from the case by the court.

2.3.20 Confidential Medical Information Questions Page (Common) The following text and questions should be presented to the Applicant. A “Yes” or “No” answer is required for each question. If the Applicant answers “Yes” to any of the questions, a text box must be presented to the Applicant to enter a supplemental explanation. There must be a separate supplemental explanation for each yes answer.

The following text should appear on the page:

“If answering "Yes" to any of the questions, you must provide the requested additional details. For purposes of the following questions, "currently" does not mean on the day of, or even the weeks or months preceding the completion of this application. It means recently enough to have an impact on one's functioning as a licensee, or within the past two years.”

· Do you have a medical or physical condition that currently impairs your ability to practice medicine?

· Have you engaged in the use of any substance(s) with the result that your ability to practice medicine is currently impaired?

· Have you ever refused to submit to a test to determine whether you had consumed and/or were under the influence of chemical substances?

“If you have a substance use disorder or mental or physical health diagnosis that impacts your ability to practice medicine, the Board encourages you to seek assistance voluntarily and to abide by any recommendations of your health care provider.

When the Board receives notice of a substance use disorder, its primary mission is to protect the public; however, the Board also seeks to ensure successful rehabilitation through the…